‘Hypertension’ and ‘high-normal’ labels may cause more harm than good in low-risk patients
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Labeling low-risk individuals based on a high BP reading led to increased worry and disease perceptions and no changes in willingness to make lifestyle changes, researchers reported.
“This is the first randomized investigation comparing the effect of different guideline labels for high BP (‘hypertension’ vs. ‘high-normal’ BP vs. control) on psychosocial and behavioral outcomes,” Danielle Marie Muscat, PhD, research fellow in the School of Public Health at the University of Sydney, and colleagues wrote in Circulation: Cardiovascular Quality and Outcomes.
For a randomized trial that enrolled 1,318 Australians from an online panel, researchers randomly assigned to one of three hypothetical scenarios in which a general practitioner told participants they had a BP reading of 135/85 mm Hg, describing it as hypertension, high-normal BP or under control. The primary outcomes were participant worry about CVD risk and willingness to change diet as assessed by an online questionnaire. Secondary outcomes included willingness to exercise, accept medication or change health behavior, perceived illness severity and other psychosocial outcomes.
Impact of labels on health
Researchers found no difference in willingness to change diet across BP label groups (P = .22) and no evidence that the hypertension label or the high-normal BP label increased willingness to exercise (P = .8).
According to the study, label of hypertension (mean difference, 0.74; 95% CI, 0.41-1.06; P < .001) and high-normal BP (mean difference, 0.45; 95% CI, 0.12-0.78; P = .008) conferred increased worry about CVD risk compared with a label of under control.
The hypertension label increased willingness to accept BP-lowering medication compared with the under-control label (mean difference, 0.2; 95% CI, 0.04-0.36; P = .014), but the high-normal label did not (mean difference, 0.06; 95% CI, 0.1 to 0.21; P = .49).
Moreover, participants assigned the hypertension and high-normal labels reported psychosocial differences such as perceived severity, more negative affect, illness perceptions and beliefs and overall happiness compared with control (P for all < .001). “These findings suggest that labeling low-risk people based on systolic BP readings that are 130 to 140 mm Hg may be more likely to harm than to benefit,” the researchers wrote. “Our findings showed increased risk perceptions, worry, negative affect and perceived negative impacts on life (eg, obtaining health and travel insurance) when both ‘hypertension’ and the ‘high-normal’ label were used. While these findings are novel for the ‘high-normal’ label, they are consistent with a longstanding body of work examining the potential harmful impacts of the ‘hypertension’ label.”
Participants were also randomly assigned to additional information about absolute risk; however, in the hypertension group, the additional information led to a decreased willingness to change diet (mean difference, 0.25; 95% CI, 0.1-0.41; P = .001) and lower willingness to increase exercise (mean difference, 0.28; 95% CI, 0.11-0.45; P = .001), compared with the control group.
‘First, do no harm’
“The findings from this study are a timely reminder of the Hippocratic oath, ‘First, do no harm,’” Anastasia S. Mihailidou, PhD, head of the cardiovascular and hormonal research laboratory at Kolling Institute in Sydney, wrote in a related editorial. “Advising people that they are hypertensive or high normal when they have low risk of cardiovascular disease potentially may cause harm rather than engage them. Since guidelines are evidence-based, they should also consider the increasing evidence of patients’ responses to having a medical label because words do matter to the patients. And this possibility for harm is only amplified if this may lead to initiating treatment with potential side effects.”
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This thorough randomized study by Muscat and colleagues arrives at the conclusion that labeling low-risk people based on systolic BP readings between 130 and 140 mm Hg may be more likely to harm than to benefit. There is little question that labeling a previously healthy person with a disease comes at a cost. The act of labeling someone as hypertensive not only triggers absenteeism, neuroticism, anxiety and perception of poor health, but also may cause a subsequent increase in BP, most probably mediated by increased sympathetic activity. Thus, becoming aware that one has hypertension may beget more hypertension. However, regardless of the outcome, physicians have no choice but to confront patients with the facts, ie, the results of an examination.
What is more bothersome is that lowering the threshold of markers that indicate “disease” has become a fashionable trend in contemporary CV medicine. The intent is to identify diseases at the earliest stage possible, so treatment can be initiated before harm has been done. Currently, it has become a ubiquitous phenomenon: levels deemed no longer acceptable of BP, lipids, glycemia, BMI and estimated glomerular filtration rate have all been set lower. However, such reclassification can be considered like substituting the fishing rod by a fishing trawler, thereby capturing many more innocent subjects than it should.
As the study also documents, adherence to so-called nonpharmacological intervention or lifestyle modifications is notoriously poor in most patients in general and in the elderly specifically. This simply means that among the more than 30 million U.S. adults who as per the ACC/AHA guidelines now meet the new definition of hypertension but in whom nonpharmacological intervention only is advised, most will never reach the target of consistently having a BP of less than 130/80 mm Hg. Any attempt to postpone antihypertensive therapy in favor of lifestyle changes will merely accelerate target organ disease.
The aim of the study was to investigate the potential benefits and harms of the “hypertension” label. There is little doubt that with the current guidelines this label carries more harm than benefits. Perhaps the good news is that the hypertension, but not high-normal, label increased willingness to accept BP-lowering medication. However, we should not forget that willingness to change diet or increase exercise primarily remains the patient’s responsibility.
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